Analysis of Sina Mehr Fire Accident Using AcciMap and STAMP Methods

Medical centers, as complex technical-social systems, are exposed to the risk of fire incidents. This study analyzes the causes and contributing factors of the fire accident at Sina Mehr Clinic to prevent similar accidents, resulting in 19 deaths and 14 injuries.

The causes and contributing factors for accidents in medical centers are found through studies related to laws and regulations, official accident reports, expert reports of regulatory bodies, interviews with experts, and review of past studies, extraction, and categorization. Accident analysis methods included AcciMap and STAMP. Finally, experts’ opinions were used to confirm and strengthen the findings.

The most critical root and hierarchical causes of the weakness of medical center management in the field of safety, dangerous conditions, fire accidents, and emergency response are the issuance of a legal building completion permit for a building that violates national building regulations and the issuance of a legal permit for a medical institution for a building with residential use, as well as the insufficiency of supervision by government and public institutions with horizontal relationships with each other and vertical relationships with universities of medical sciences, labor offices, and firefighting organizations, as the direct supervisors of medical centers.

The AcciMap and STAMP findings indicate that the priority is to amend the regulations for the establishment, operation, and activity of medical centers with an emphasis on safety regulations, as well as the frequency and shortening of feedback loops such as inquiring about the building completion permit from the municipality, announcing the establishment of a medical center to other governmental and public supervisory authorities, and the reporting of unsafe cases directly by supervisors to the Ministry of Health. Legal authorities are the most crucial cycle in the resilience of fire incidents and their consequences in medical centers.